Provider Demographics
NPI:1013215714
Name:KELDAHL, HEATHER (CRNA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KELDAHL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 W WAVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4949
Mailing Address - Country:US
Mailing Address - Phone:630-835-9121
Mailing Address - Fax:312-942-5773
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:JELKE 739
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6504
Practice Address - Fax:312-942-5773
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-008545364S00000X
IL209008545041346941367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist